NCP Guidelines: Domain 1 - Structure and Processes of Care
December 8, 2018
Accountable Health Communities = CBPC
January 7, 2016
Wow! That's what I thought when I saw Diane Meier's tweet and read about the latest Centers for Medicare and Medicaid Services innovation project, Accountable Health Communities. The model is predicated on "emerging evidence that addressing health-related socials needs through enhanced clinical-community linkages can improve health outcomes and reduce costs." The program will fund 44 cooperative agreements to organizations to "partner with state Medicaid agencies, clinical delivery sites, and community service providers."
The entire focus of this model is to integrate clinical care with services aimed at improving social determinants of health. This is what palliative care providers do! This is the essence of palliative care -- a holistic healthcare delivery system.
I haven't had time to thoroughly read the entire announcement yet. Here are the high points. The model promotes overall health for community-deweling Medicaid and Medicare beneficiaries through:
Screening for unmet health-related social needs;
Referral to increase awareness of community services;
Provision of navigation services to assist high-risk beneficiarie access community services; and
Aligning between clinical and community services so that community services are available and responsive to the needs of beneficiaries.
CMS is seeking three kinds of proposals for organizations to serve as the "hub responsible for coordinating" efforts to:
Track 1 Awareness – Referral to community organizations
Track 2 Assistance – Referral and navigation services to assist high-risk beneficiaries access services
Track 3 Alignment – Referral, navigation services and quality improvement focused on care alignment
Each organization selected will:
Identify and partner with providers;
Conduct health-related social needs screenings and make referrals for all eligible Medicare and Medicaid beneficiaries;
Coordinate and connect beneficiaries who screen positive for certain unmet needs with community service providers able to address those needs; and
Align model partners to optimize community capacity to address health-related social needs (Track 3 only).
Here's my preliminary takeaway -- this model seeks to develop a continuum of care for high-risk individuals living in the community. These will likely include the population that community-based palliative care programs want to serve -- as well as other Medicare and Medicaid beneficiaries.
I believe that organizations providing, developing, or even contemplating developing a community-based palliative care program should be working now to:
Decide if they have the capacity to implement this type of cooporative agreement (most likely beyond the scope of a single community-based hospice or palliative care program);
Reach out to existing partners, such as large health systems or national vendors to explore whether or not they intend to apply; and
Establish partnerships with applicants to receive referrals, provide navigation services and deliver palliative care to high-risk beneficiaries.
I'd love to hear thoughts from you about this model and the potential for this to serve as a catalyst for palliative care referrals.